USVI ENROLLMENT APPLICATION

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NOTE: USVI GOVERNMENT EMPLOYEES, CONTACT GLOBAL MEDEVAC DIRECT:
340-776-6822 • #2 Tenth Street, St. Thomas, VI 00802

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    Primary Member Information:

    Note: Preexisting conditions are covered after 90-days

    Member's Spouse Information:

    Note: Preexisting conditions are covered after 90-days

    Dependent's Information:

    Note: Preexisting conditions are covered after 90-days

    Second Dependent's Information:

    Note: Preexisting conditions are covered after 90-days

    Home Benefits Address:

    Mailing Address (IF DIFFERENT FROM HOME BENEFITS ADDRESS):

    Agent Information:

    Preferred Payment Method: *

    Note: a Global Medevac agent will reach out to you to process your payment

    REFERRAL INFORMATION:

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